Transcript Nessun titolo diapositiva

13th Congress of Mediterranean League
of Angiology and Vascular Surgery
Syracuse - May 21-25, 2003
G.Bandiera, C.Cirielli, F.M. Di Paola, G.Dompè, L. Mascellari, F. Serino
Carotid Revascularization Surgery:
Our Experience
III Divisione di Chirurgia Vascolare
(Primario: G. Bandiera)
Carotid Endarterectomy(CE)
1953: De Bakey performs first CE.
ToDay: Carotid Endarterectomy constitutes
one of the most frequently performed surgical
procedures in the theatres of vascular surgery,
and accounts for hundreds of thousands of
operations carried out world-wide every year.
III Divisione di Chirurgia Vascolare
(Primario: G. Bandiera)
Carotid Endarterectomy (CE)
The excellent short- and long-term results
and the low rate of perioperative
complications have encouraged a sort of
“deregulation” of the indications that have
been extended also to non-symptomatic
patients
III Divisione di Chirurgia Vascolare
(Primario: G. Bandiera)
Carotid Endarterectomy (CE)
Hence the necessity of performing audited
clinical studies, rigorous prospective and
randomized trials and it has thus possible to
set out guidelines on surgical treatment of the
atherosclerotic pathology of the carotid axis
III Divisione di Chirurgia Vascolare
(Primario: G. Bandiera)
Carotid Endarterectomy (CE)
A fundamental concept clearly emerges from
these studies: the atherosclerotic plaque that
determines a “significant” carotid stenosis
should be considered at risk (therefore
deserving of surgical treatment) if it is already
“symptomatic”, i.e. already responsible for
transient cerebral ischaemia or minor stroke
III Divisione di Chirurgia Vascolare
(Primario: G. Bandiera)
The “symptomatic” carotid
• T.I.A. = Transient Ischaemic Attack (<24 hours)
• R.I.N.D. = Reversible Ischaemic Neurological
Deficit (>24 hours and <3 weeks)
• P.R.I.N.D. = idem, “Partially” Reversible
• Stroke = Mortal, Severe or Persistent Neurological
Deficit
III Divisione di Chirurgia Vascolare
(Primario: G. Bandiera)
Symptomatic patients selection
• ECST (European Carotid Surgery Trial):
the “threshold” limit for the surgical
treatment of a carotid stenosis is 70-80%
• NASCET (North American Symptomatic
Carotid Endarterectomy):
EC in patients with stenosis between 50 and
69% offers a slight but significant advantage
III Divisione di Chirurgia Vascolare
(Primario: G. Bandiera)
ipsilateral stroke rates
Stenosis Trial
Surgery Follow up % of Risk
%
%
%
reduction
0-49 NASCET 14.9
18.7
3.8% at 5yrs
p
= 0.16
50-69
NASCET
15.7
22.2
6.4% at 5yrs
80-00
ECST
6.8
20.6
13.8% at 3yrs <0.0001
70-99
NASCET
9.0
26.0
17% at 2yrs
<0.045
<0.001
III Divisione di Chirurgia Vascolare
(Primario: G. Bandiera)
Apparent discrepancy due to the
different methods used to measure
the grade of stenosis
III Divisione di Chirurgia Vascolare
(Primario: G. Bandiera)
external
carotid
internal
carotid
hypothetic position
of the carotid wall
common carotid
A-B
NASCET
A
ECST
C-B
C
NASCET
ECST
30
65
40
70
50
75
60
80
70
85
80
91
90
97
Comparison of the
grade of stenosis of
the I.C. evaluated
according to NASCET
and ECST
Symptomatic p.ts, 30 days follow up:
ECST
NASCET
deaths
1.0%
1.1%
invalidating strokes
2.5%
1.8% (1/3 intraop.)
non-invalidating strokes
3.5%
4.5% (2/3 postop.)
ECST (European Carotid Surgery Trial) Lancet, 1998;351:1379
NASCET (North American Symptomatic Carotid
Endarterectomy Trial) Ferguson GG et al., Stroke, 1999;30:1751
III Divisione di Chirurgia Vascolare
(Primario: G. Bandiera)
NASCET (North American Symptomatic Carotid
Endarterectomy Trial) Ferguson GG et al., Stroke, 1999;30:1751
Other complications in 1415 symptomatic operated patients
wound:9.1% (3% severe)
haematomas:
7.0%
cranial nerve lesions : 8.6%
(none severe)
infections:
2.0%
facial:
2.2%
others:
0.1%
vagus:
2.5%
Stroke at 2 years:
access. spinal:
0.2%
operated: 9%
hypoglox:
3.7%
non-operated controls: 26%
III Divisione di Chirurgia Vascolare
(Primario: G. Bandiera)
The “asymptomatic” carotid
How to act in front of a carotid stenosis,
superior than a certain degree and with
specific composition and morphology
characteristics, equally at risk even if still
“asymptomatic”?
III Divisione di Chirurgia Vascolare
(Primario: G. Bandiera)
Asymptomatic patients selection
• AHA (American Heart Association)
• SICVE (Società Italiana di Chirurgia Vascolare ed
Endovascolare)
III Divisione di Chirurgia Vascolare
(Primario: G. Bandiera)
ACAS (American Carotid Asymptomatic Study)
Jama, 1995;273:1421
Stroke and/or correlated death at 2.7 years in
1662 pt.s:
•5.1% in operated pt.s
•11.0% in non-operated controls
(= risk reduction: 53%)
III Divisione di Chirurgia Vascolare
(Primario: G. Bandiera)
carotid revascularization surgery
•
•
•
•
•
CE alone
CE + angioplasty (vein or PTFE patch)
Eversion CE
Bypass (vein or PTFE or Dacron)
Graft interposition (vein or PTFE or Dacron)
III Divisione di Chirurgia Vascolare
(Primario: G. Bandiera)
Anatomic features
Nerve lesions
r. buccale
ipoglosso
faciale
r. mandibolare
vago
r. discendente
The ideal technique should assure:
- low incidence of peri- and postoperative
complications (bleeding, nerve lesions,
early occlusion, TIA and/or stroke)
- restenosis prevention
III Divisione di Chirurgia Vascolare
(Primario: G. Bandiera)
CE with direct suture
CE with direct suture
pros:
- easier and quicker
- less clamping time
- less bleeding
CE with direct suture
cons:
- early occlusion
- restenosis
CE + patch angioplasty
pros:
- reduced restenosis risk
cons:
- longer clamping time,
- two sutures instead of one,
- interposition of material
(risk of infection, pseudoaneurysms, occlusions)
EC vs Ec+patch: incidence of thrombosis of
I.C., stroke at 30 days and restenosis
(Archie JP, Semin Vasc Surg, 1998, 11: 24-29)
10
Sutura diretta
8
7,4
Patch
6
p<0.001
%
4,3
4
2
0
3,9
p=0.001
0,8
462 641
Occlusione
2,1
p=0.008
1,2
462 641
Ictus
448
591
Restenosi > 50%
use of the patch in Europe
(by Bond. R. et al., Eur J Vasc Endovasc Surg 23, 117.126, 2002)
81 77
47
37 36 35 32
21 17 15 13
er
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nd
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ar
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an
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100
80
60
40
20
0
G
% interventi con patch
Uso del Patch
Centri
2
Use of the patch
Favourable clinical conditions for its use:
- female gender,
- diameter of the internal carotid < = 5 mm
- wide distal extension of the CE,
- application of Kunlin’s suture
III Divisione di Chirurgia Vascolare
(Primario: G. Bandiera)
CE Eversion
elective indications:
stenosing kinking or plication of the I.C.
ats plaque placed at the bulb origin of the I.C.
pro:
- rapid suture, minor risk of restenosis
cons:
- poor control of the
distal end-point of the CE
-difficulty in placing
the shunt
-
-
In the CE by eversion, in some cases, the use
of the shunt can facilitate the completion of
the procedure: once placed, the I.C. can be
everted onto the same shunt used like a
“mandrin” to remove completely the plaque
and evaluate the distal end-point.
Eversion CE
by Cao P.G et al., 2002
Shunt or no shunt?
Total
NO Emboli
NO Shunt
73 (62%)
54
Shunt
44 (38%)
10
Emboli
19 (26%)
34 (77%)
Gordon JK, 1996
cons:
major risk of microembolies,
major duration of the surgery
III Divisione di Chirurgia Vascolare
(Primario: G. Bandiera)
Indications for bypass or graft interposition
- carotid restenosis (post CE, post stenting),
- aneurysms (on ats basis or post-traumatic),
- post CE+patch pseudo-aneurysms both
sintetic and venous),
- acute dissection of the I.C. (ats, fibre-muscular
dysplasia, cystic necrosis of the media),
- particular conditions, were the ats of the I.C.
does not allow CE to be performed
III Divisione di Chirurgia Vascolare
(Primario: G. Bandiera)
common c.- internal c. bypass (vein)
End to end anastomosis
graft (or vein) interposition
external carotid endarterectomy
indicated in case of:
- TIA or amaurosis fugax in presence of I.C.
occlusion and E.C. stenosis
- In the pre-occlusive stenosis of the I.C. with
a poor back-flow and with
a fibrotic and small I.C.
tecnique:
- exploration of the I.C. and
back-flow assessment
- ligature of the I.C.
- CE of the E.C. with or without patch
carotid kinking
indicated in case of:
- symptomatic kinking
- excessive I.C. redundancy
dissection and mobilisation
after
its
surgical technique:
- eversion CE (kinking+plaque)
- I.C. resection + T-T anast. on I.C. or C.C.
- C.C. resection with lowering of the
bifurcation and T-T anast.
III Divisione di Chirurgia Vascolare
(Primario: G. Bandiera)
Resection-anastomosis of the internal carotid
proximal common carotid
in Takayasu’s Disease (multifocal distribution):
- bypass between the ascending Ao and the
distal C.C. or C.I.
in ats, with severe stenosis or C.C. occlusion in
symptomatic patients:
- extra-anatomic bypass
III Divisione di Chirurgia Vascolare
(Primario: G. Bandiera)
subclavian-carotid bypass
It is better to associate the subclavian-carotid
bypass with the ligature of the proximal C.C.
(when this is not occluded) upstream of the
distal anastomosis of the
bypass, to avoid postoperative late embolisms.
The use of Dacron or
PTFE prostheses are
preferable to the vein
Another technique used to avoid the implant
of a synthetic prosthesis is the
Transposition of the
C.C. onto the ipsilateral
subclavia
carotid-carotid bypass
indicated for:
high risk patients for sternotomy and with
ats of the ipsilateral subclavia.
tecnique:
The bypass (Dacron,PTFE,vein)
from donor C.C. to the recipient
C.C. is in the retropharingeal
space. The CE of the bifurcation
can precede distal anastomosis
(T-T or T-L)
III Divisione di Chirurgia Vascolare IRCCS - IDI
(Primario: G. Bandiera)
5/1997 - 4/2003
333 p.ts (206 males and 127 females)
symptomatics: 102 (30.6%)
asymptomatics: (stenosis>70-75%): 231 (69.4%)
stenosis: 303 (91%),
stenosing kinking: 16 (5.1%)
re-stenosis: 7 (2.1%)
bilateral stenosis of I.C. 80 (24%)
III Divisione di Chirurgia Vascolare IRCCS - IDI
(Primario: G. Bandiera)
5/1997 - 4/2003
General anaesthesia: 279 cases (83.8%)
Stump Pressure: 279 cases (100%)
Shunt for S.P. < 30 mmHg: 43 (15.4%)
Loco-regional anaesthesia: 54 cases (16.2%)
Shunt: 7 (13%) due to loss of consciousness
(conversion into general anaesthesia has never
been necessary).
III Divisione di Chirurgia Vascolare IRCCS - IDI
(Primario: G. Bandiera)
5/1997 - 4/2003
Interventions: 333
CE+ direct suture: 199 (59.7%)
CE+ patch angioplasty: 101 (30,3%)
CE Eversion: 19 (5.7 %)
CC-CI bypass: 9 (2.7%) (5 S.I., 4 PTFE)
Subclavian-Carotid bypass: 4 (1,5%) (2 S.I., 2 PTFE)
III Divisione di Chirurgia Vascolare IRCCS - IDI
(Primario: G. Bandiera)
5/1997 - 4/2003
Peri-operative results
ECST
NASCET
Personal
deaths
1.0%
1.1%
2 (0.6%)
invalidating stroke
2.5%
1.8%
(1/3 intraop.)
2 (0.6%)
non-invalidat. stroke 3.5%
4.5%
(2/3 postop.)
6 (1.8%)
III Divisione di Chirurgia Vascolare IRCCS - IDI
(Primario: G. Bandiera)
5/1997 - 4/2003
Peri-operative results
NASCET
Personal
wound:
9,1%
15 (4.5%)
haematomas:
infections:
others:
7.0%
2,0%
0.1%
15 (4.5%)
0
0
cranial nerve lesions:
8,6%
4 (1.2%)
facial:
vagus:
access. spinal:
hypoglossus:
2.2%
2.5%
0.2%
3.7%
1 (0,3%)
0
0
3 (0,9%)
III Divisione di Chirurgia Vascolare IRCCS - IDI
(Primario: G. Bandiera)
5/1997 - 4/2003
Follow-up results (75-1 months - mean: 32 months)
occlusions
sympt.
asympt.
restenosis
signif.
non-sign.
• symptomatic p.ts
1
0
1
0
• asymptomatic p.ts
2
1
5
3
•CE alone
3
1(10m.)
4(6,15,20,39m.)
3(24,26,36m.)
•CE + patch
0
0
0
0
•CE eversion
0
0
1
0
•CC-IC bypass (saph.)
0
0
1(6m.)
0
III Divisione di Chirurgia Vascolare
(Primario: G. Bandiera)
•
•
•
•
•
•
•
•
•
•
•
CE in GENERAL ANAESTHESIA
general anaesthesia:
303 (91%)
anaesthesia of the glomus:
lidocain 1%: 1-2 ml
systemic heparin :
1 mg/kg b.w. (2 mg if shunt)
stump pressure:
always
shunt in:
if stump press.<30 mmHg
vessel cloud:
always (rarely clamps)
heparinized solution:
intravasal and for cleaning
if direct suture :
polypropilen 5 or 6.0
if patch:
PTFE and PTFE suture 6.0
aspirating drainage :
always (removed in I-II p.o.)
Intensive Care:
24 hours
III Divisione di Chirurgia Vascolare
(Primario: G. Bandiera)
CE in GENERAL ANAESTHESIA
• if stump press.<30 mmHg: always shunt
III Divisione di Chirurgia Vascolare
(Primario: G. Bandiera)
•
•
•
•
•
•
•
•
•
•
•
CE in LOCAL ANAESTHESIA
local anaesthesia :
54 (13%)
anaesthesia of the glomus:
lidocain 1%: 1-2 ml
sistemic heparin :
1 mg/kg b.w. (2 mg if shunt)
patient monitoring :
verbal-motory (squeezing)
shunt:
if clamping intolerance
vessel cloud:
always (rarely clamps)
heparinized solution:
intravasal and for cleaning
if direct suture :
polypropilen 5 o 6.0
if patch:
PTFE and PTFE suture 6.0
aspirating drainage :
always (removed in I-II p.o.)
Intensive Care:
0-24 hours
III Divisione di Chirurgia Vascolare
(Primario: G. Bandiera)
CE in LOCAL ANAESTHESIA
•premedication: meperidina 100mg+atropina 0.5mg+deidrobenzoperidolo 1.25mg
•sedation: remifentanil 0.04microg/Kg/min in infusione continua
•anaesthetic: ropivacaina
•superficial cervical block:12 ml(0.5%)
•deep cervical block: 21 ml(0.7%)
Moore Technique:
3 injections at C2,C3.C4 levels